Distal Endarterectomy Combined With Endovascular Proximal Treatment: The Hybrid DEEP Retrograde Technique for
Luis J García Domínguez1, Irene Ramos Moreno1, Rafael Martinez López1
1Vascular Surgery Department, Hospital Universitario y Politécnico la Fe, Valencia, Spain.
Insights
This study introduces the DEEP technique, a hybrid approach combining open distal endarterectomy and endovascular treatment for chronic limb-threatening ischemia (CLTI). The DEEP technique shows promising short-term results for limb salvage in complex infrainguinal disease.
Area of Science:
- Vascular Surgery
- Endovascular Interventions
- Peripheral Arterial Disease
Background:
- Chronic limb-threatening ischemia (CLTI) presents a significant challenge, often requiring complex revascularization strategies.
- Infrainguinal disease, particularly multilevel occlusions and severe calcification, poses difficulties for traditional bypass surgery.
- The absence of suitable autologous vein grafts or high surgical risk can limit treatment options for CLTI patients.
Purpose of the Study:
- To present a novel hybrid technique, termed the DEEP technique, for treating CLTI caused by complex, multilevel infrainguinal arterial disease.
- To evaluate the safety and efficacy of this hybrid approach, combining open distal endarterectomy with endovascular proximal treatment.
- To assess the feasibility of the DEEP technique in patients with challenging anatomy or high surgical risk.
Main Methods:
- A prospective cohort study involving 33 limbs (30 patients) with complex infrainguinal disease.
- The DEEP technique involved open distal endarterectomy and retrograde endovascular treatment using a covered stent.
- Inclusion criteria focused on patients with complex infrainguinal patterns, absence of suitable vein for bypass, or high surgical risk.
Main Results:
- Effective revascularization was achieved in all cases, with a significant improvement in ankle-brachial index (ABI) from 0.3 to 0.9.
- At 12 months, the limb salvage rate was 93.9%, primary patency was 75.7%, assisted primary patency was 84.6%, and secondary patency was 90.9%.
- Major adverse limb events (MALE) occurred in 24.2% and major adverse cardiovascular events (MACE) in 6% of patients, with a mean postoperative stay of 7.5 days.
Conclusions:
- The DEEP technique is a less invasive hybrid approach with promising short-term outcomes for limb salvage in selected CLTI patients.
- This technique offers a viable alternative for revascularization in cases of complex infrainguinal disease, especially when traditional bypass is not feasible.
- The DEEP technique warrants consideration as part of the vascular armamentarium for managing CLTI.
Abstract:
Purpose: We present a hybrid technique for the treatment of chronic limb-threatening ischemia (CLTI) due to complex, multilevel infrainguinal disease. It consists of an open distal endarterectomy combined with endovascular proximal treatment (the DEEP technique). Materials and Methods: This was a prospective cohort study. Thirty-three limbs (30 patients) were treated. Main inclusion criteria were absence of significant disease in femoral bifurcation associated with a complex infrainguinal pattern. This approach was specially considered in absence of suitable vein for bypass, obesity, hostile groin, and overall high surgical risk. Results: Mean age was 72.8 ± 10 years (ranging 50-93). Most cases presented with severe limb threatening onset (90.9% Rutherford >4 and 81.8% WIfi >3) due to high-complexity infrainguinal disease pattern (Global Limb Anatomic Staging System [GLASS] stage III) in 31/33 (93.9%), chronic total occlusions (CTOs) in 24/33 (72.7%), and severe calcification (Peripheral Arterial Calcium Scoring System [PACSS] grade 4) in 22/33 (66.6%). Mean lesion length was 228.2 mm ± 83 (ranging 40-340 mm). In all procedures, a covered-stent (25 cm length Viabahn) was implanted in a retrograde fashion as the endovascular component. Effective revascularization was achieved in all cases, showing significant clinical and hemodynamic improvement (median pre- and postprocedure ankle-brachial index [ABI]: 0.3 and 0.9, respectively). Results at 12 months follow-up were as follows: 93.9% limb salvage ratio, 75.7% primary patency, 84.6% assisted primary patency, and 90.9% secondary patency. Major adverse limb events (MALE) and cardiovascular events (MACE) occurred in 8/33 (24.2%) and 2/33 (6%), respectively. Mean length of postoperative stay was 7.5 ± 6.92 days (3-27). Conclusion: This less invasive hybrid technique has promising short-term results for limb salvage and it is worth to be included in vascular armamentarium for CLTI revascularization in selected patients.
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